I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
Choice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive...
I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
Choice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive medication may be inappropriately discontinued.
References
(1) Jolobe, OMP
Mythmaking in the measurement of blood pressure
European Journal of Internal Medicine 2014;25:e11
(2)Liamis G., Filippatos TD., Elisaf MS
Thiazide associated hyponatremia in the elderly;what the clinician needs to know
Journal of geriatric cardiology 2016;13:175-182
(3) Barber J., McKeever TM., McDowell SE., Clayton JA., Ferner RE., Gordon RD et al
A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation?
BJCP 2014;79:566-577
(4) Burst V., Grundmann F., Kubacki T., Greenberg A., Becker I., Rudolf D., Verbalis J
Thiazide-associated hyponatremia, Report of hyponatremia registry: An observational multicenter International Study
Am J Nephrology 2017;45:420-430
(5) Chapman MD., Hanrahan R., McEwen J., Marley JE
Hyponatraemia and hypokalaemia due to indapamide
Med J Aust 2002;176:219-221
(6)Yong TY., Huang JE., Kau SY., Li JY
Severe hyponatremia and other electrolyte disturbances associated with indapamide
Curr Drug Saf 2011;6:134-137
Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.
As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.
Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.
Earlier this year a cohort study at the University of Dundee showed t...
Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.
As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.
Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.
Earlier this year a cohort study at the University of Dundee showed that positive experience in medical school was the biggest influencer in career choice and that almost half of students were following the career consistent with their first choice at final year, highlighting the longevity of these positive experiences (3).
Therefore, in order to encourage uptake for training in specialties such as general practice, targeting students who have not yet left medical school (and therefore are more likely to be more open minded about career choice) may be an effective recruitment strategy. Furthermore, this strategy could focus on establishing a positive experience for medical students whilst on clinical placements.
Considering this, whilst current recruitment strategies such as salary supplements for GP trainees in low-recruitment areas are no doubt important, they may be missing some of their most impressionable audience. By developing a broader interest in GP specialty during medical school through positive clinical experiences, students may be more motivated to tackle the issues within general practice and therefore more likely to take up in training in areas where historically recruitment has been low.
Taking a broader, grass-roots approach to recruitment of low uptake specialties may result in more final-year students with realistic and long-standing career aspirations within these specialties. Building on the conclusions in the report discussed here, medical school experience is a known determining factor in the career choice of junior doctors. Therefore, it may be important to identify the factors that make clinical placement experience positive or negative, in order to improve placement experience and ultimately promote uptake of specific specialties, such as general practice.
1. Lambert TW, Smith F, Goldacre MJ. Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys. Postgrad Med J [Internet]. 2018;postgradmedj – 2017–135309.
2. Woolf K, Elton C, Newport M. The specialty choices of graduates from Brighton and Sussex Medical School: a longitudinal cohort study. BMC Med Educ. 2015;15:46.
3. McNaughton E, Riches J, Harrison G, Mires G, MacEwen C. What factors influenced the choice of medical specialty for doctors surveyed in the final year at medical school and again having entered their specialty training destination? Postgrad Med J [Internet]. 2018;0(0):postgradmedj – 2017–135370.
Sir,
In recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine be...
Sir,
In recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine because practitioners may develop a casual attitude that accepts suboptimal outcomes. Lastly, if comprehensive solutions are not sought to tackle the burnout, and only the medical community is asked to resort to resilience every time, the morale of the practitioners may decrease and eventually, this may be reflected in poorer patient care.
In summary, though promoting resiliency among physicians has a role to play in improving the present day`s besetting healthcare scenario, looking it at as a ‘one-stop solution' to physician burnout could be counterproductive. As appreciated by the systematic review itself, there is a definitive need for a holistic approach, addressing the multitude of problems contributing to the burnout among trainees and practitioners rather than over stressing on resiliency strategies.
Acknowledgement: Nil
Conflicts of interest: None
References
1. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Pract Manag. 2013;20:25–30.
2. Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26:858–61.
3. Launer J. Resilience: for and against. Postgrad Med J. 2015;91:721–2.
4. Fox S, Lydon S, Byrne D, Madden C, Connolly F, O’Connor P. A systematic review of interventions to foster physician resilience. Postgrad Med J. 2017 Oct 10 [cited 2017 Dec 26]. doi: 10.1136/postgradmedj-2017-135212. [Epub ahead of print].
It was a pleasure reading Fitzgerald’s study on provision of research/audit opportunities and skills required to conduct such projects[1]. As medical-students, it was revealing to read statistics on how our contemporaries reported lack of formal research opportunities and training. As part of Europe’s largest medical school[2], one with a strong reputation that no doubt hinges on viable research output, we were not surprised by these results.
Though we agree with the article’s conclusions, we’d like to offer our thoughts on factors affecting student output and improvements that could be made.
From our experience, the main ways students are granted research opportunities are through Student Selected Components (SSCs) and intercalated BScs. Timescales for these are 5-6 months, with most having a shorter duration. Usually this is enough for a topic introduction, let alone information accumulation for an acceptable paper. Moreover, iBSc-derived research offers opportunities to access respected research teams and get better publications. We know students published in Nature due to their iBSc modules[3]. However, these modules are invariably oversubscribed, meaning students without sufficient marks are often excluded. Lastly, because of time and location demands on students during clinical years, it is likely most student publications come from research exposure during iBSc. The importance of this publication route needs further investigation....
It was a pleasure reading Fitzgerald’s study on provision of research/audit opportunities and skills required to conduct such projects[1]. As medical-students, it was revealing to read statistics on how our contemporaries reported lack of formal research opportunities and training. As part of Europe’s largest medical school[2], one with a strong reputation that no doubt hinges on viable research output, we were not surprised by these results.
Though we agree with the article’s conclusions, we’d like to offer our thoughts on factors affecting student output and improvements that could be made.
From our experience, the main ways students are granted research opportunities are through Student Selected Components (SSCs) and intercalated BScs. Timescales for these are 5-6 months, with most having a shorter duration. Usually this is enough for a topic introduction, let alone information accumulation for an acceptable paper. Moreover, iBSc-derived research offers opportunities to access respected research teams and get better publications. We know students published in Nature due to their iBSc modules[3]. However, these modules are invariably oversubscribed, meaning students without sufficient marks are often excluded. Lastly, because of time and location demands on students during clinical years, it is likely most student publications come from research exposure during iBSc. The importance of this publication route needs further investigation.
Even after iBSc, a crash course in advanced ‘basic science’, we do not feel we retained skills needed to deal with research problems. From the oft-dry presentation of statistics in pre-clinical years, we understand it’s hard to teach and appears effortful to the uninitiated. We believe a well-organised research curriculum can overcome this. Assigning small groups specific teachers passionate about their subject is one option, as is organising research weeks separate from lectures/clinical teaching so students in early years of medical-school have a solid grounding on the topic and don’t have to deal with existing widely-spaced tutorials. While we appreciate this is costly, a recent US study showed 14 students produced 68 abstracts and 34 papers on a Masters of Science/MD program where research skills were prioritised, with more in submission and awaiting publication[4]. With this kind of productivity in mind, should students become interested in research, there may be financial benefits to their institution by way of accessing research grants.
Lastly, we found that as low-yield PowerPoints, students discard lectures on research after they lose their relevance to exams. The ‘At A Glance’ book series has proved popular amongst medical-students as material is presented in a high-yield way, meaning students learn a lot from a few pages’ reading. Making ‘At a glance’ booklets for components of a research project to be covered in sessions could engage students earlier. A few days covering hypothetical research projects with these resources (or having webinars to watch in our spare time) would give the university's approach to research structure, and thus make it more enjoyable as part of the medical-school curriculum.
With these changes, we believe student research uptake would be greater and more successful projects would be completed.
References:
1. Medical research and audit skills training for undergraduates: An international analysis and student-focused needs assessment. Postgraduate Medical Journal Published Online First: 02 September 2017. doi: 10.1136/postgradmedj-2017-135035
3. Lobo, N., Dupré, S., Sahai, A., Thurairaja, R. and Khan, M.S., 2016. Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures. Nature Reviews Urology, 13(8), pp.447-455.
4. Gillman, J., Pillinger, M., Plottel, C.S., Galeano, C., Maddalo, S., Hochman, J.S., Cronstein, B.N. and Gold‐von Simson, G., 2015. Teaching Translational Research to Medical Students: The New York University School of Medicine's Master's of Science in Clinical Investigation Dual‐Degree Program. Clinical and translational science, 8(6), pp.734-739.
I was disappointed by this attempt to rebut my hypothesis.
My hypothesis was not inchoate (OED “confused or incoherent”) as they obviously understood exactly what I wished to suggest – the conventional wisdom might be wrong or at least need some modification and that Carbon dioxide excretion may play a part in weight regulation.1
We agree that the general public and health professionals are bewildered about weight regulation. That is not a reason to stop thinking and restate conventional wisdoms.
We agree that “the majority of people they surveyed believed that that ”fat shed during weight loss was converted to energy rather than excreted as carbon dioxide and water.” That is not a reason to stop thinking and rely upon conventional wisdoms. I recall a paper that made the point that exhaled Carbon Dioxide might be relevant to fat loss.2 Indeed most people seem to assume that weight can be lost purely by energy production “raised metabolic rates” without a net excretion of heavy atoms but this is a conventional wisdom that is only correct in nuclear reactors in which E=mc2.
Of course self –reporting of food intake is notoriously unreliable. But do we condemn as recidivists3 all those whose weigh loss plateaus on a diet? The same paper suggested a metabolic resistance to the maintenance of a reduced body weight. I merely provided a possible mechanism for this.
We agree that “diets only succeed when the age-old advice to eat less and mov...
I was disappointed by this attempt to rebut my hypothesis.
My hypothesis was not inchoate (OED “confused or incoherent”) as they obviously understood exactly what I wished to suggest – the conventional wisdom might be wrong or at least need some modification and that Carbon dioxide excretion may play a part in weight regulation.1
We agree that the general public and health professionals are bewildered about weight regulation. That is not a reason to stop thinking and restate conventional wisdoms.
We agree that “the majority of people they surveyed believed that that ”fat shed during weight loss was converted to energy rather than excreted as carbon dioxide and water.” That is not a reason to stop thinking and rely upon conventional wisdoms. I recall a paper that made the point that exhaled Carbon Dioxide might be relevant to fat loss.2 Indeed most people seem to assume that weight can be lost purely by energy production “raised metabolic rates” without a net excretion of heavy atoms but this is a conventional wisdom that is only correct in nuclear reactors in which E=mc2.
Of course self –reporting of food intake is notoriously unreliable. But do we condemn as recidivists3 all those whose weigh loss plateaus on a diet? The same paper suggested a metabolic resistance to the maintenance of a reduced body weight. I merely provided a possible mechanism for this.
We agree that “diets only succeed when the age-old advice to eat less and move more is followed so that the carbon atoms ingested are outnumbered by those exhaled.” So their point is?
I submitted a hypothesis and, in the spirit of Karl Popper, I would welcome, not further circumstantial evidence in favour of my hypothesis, but a scientific discussion why I was wrong rather than statements of conventional wisdoms. Their letter was not it.
Philip D Welsby
REFERENCES
1. Welsby PD. Why diets fail: a hypothesis for discussion.Postgrad Med J 2017;93:360-363.
2. Meerman R, Brown AJ. When somebody loses weight, where does the fat go? BMJ 2014;349:g7257.
3. Label RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. N Engl J Med1995;332:332-628.
Philip D Welsby 18/7/17
1, Burnbrae,
Edinburgh EH12 8UB
0131 339 8141 Philipwelsby@aol.com
Fake peer review: the many faces
Viroj Wiwanitkit1
1. Honorary Professor, Dr Dy Patil University, Pune Inida
Email: wviroj@yahoo.com
I read the recent publication by Cheung BMY with a great interest [1]. In fact, this problem is not uncommon and can be seen elsewhere.
Reviews that seem overtly positive can be a clue for suspicious fake reviewing. It is the role of the journal editor to select the reviewer and consider the quality of the review. The fake reviewing might be by a non-existent (totally fake) person or a disguised reviewer. Sometimes, it can be a totally biased reviewer who is recommended by the submitting author.
In addition, a similar problem can also be seen in academic presentations, proposal decisions, funding decisions, as well as academic position appointment decisions. In some underdeveloped countries, it is surprising that non-scientific reviewers can act as academic reviewers when academic work is under consideration. This reflects a poor standard and should be considered as an unacceptable misconduct.
conflict of interest
None
References
1. Cheung BMY. Fake peer review - too good to be true. Postgrad Med J. 2017 Jun 7. pii: postgradmedj-2016-134506.
Conflict of Interest
None declared
It was with great pleasure that we read the observational study by Bosner et al [1] which centres on an aspect salient to all medical students: clinical teacher feedback [2][3][4]. A factor highlighted by Lempp et al, found that students were most pleased with teachers who were approachable and provided them with constructive criticism [4].
As undergraduate medical students at the largest centre for healthcare education in Europe [5], we benefit from experiences in varied teaching settings; ranging from one-to-one sessions to class sizes of up to 450 students. Our clinical curriculum places strong emphasis in the primary health care setting - where we have accumulated nearly 300 hours between us in around 40 practices, both in and around London.
Whilst Bosner et al [1] have presented a well-organised and structured study; we challenge some of the intricacies affecting its overall validity and subsequent conclusions, and therefore propose suggestions for improvements. There is an absence of information pertaining to whether the observers (fifth year medical students) were appropriately trained to effectively judge the quality of feedback given by their seniors (clinical teachers). This is then coupled with no mention of any guidelines or reference used as a “benchmark” for this assessment. Both present issues regarding quality assurance - the necessity and impact of which has been highlighted by Lievens [6].
It was with great pleasure that we read the observational study by Bosner et al [1] which centres on an aspect salient to all medical students: clinical teacher feedback [2][3][4]. A factor highlighted by Lempp et al, found that students were most pleased with teachers who were approachable and provided them with constructive criticism [4].
As undergraduate medical students at the largest centre for healthcare education in Europe [5], we benefit from experiences in varied teaching settings; ranging from one-to-one sessions to class sizes of up to 450 students. Our clinical curriculum places strong emphasis in the primary health care setting - where we have accumulated nearly 300 hours between us in around 40 practices, both in and around London.
Whilst Bosner et al [1] have presented a well-organised and structured study; we challenge some of the intricacies affecting its overall validity and subsequent conclusions, and therefore propose suggestions for improvements. There is an absence of information pertaining to whether the observers (fifth year medical students) were appropriately trained to effectively judge the quality of feedback given by their seniors (clinical teachers). This is then coupled with no mention of any guidelines or reference used as a “benchmark” for this assessment. Both present issues regarding quality assurance - the necessity and impact of which has been highlighted by Lievens [6].
The presence of the observers may have biased general practitioner (GP) attitudes towards their respective students, an aspect which is further complicated by the fact that in some instances, none of the students collecting the data were present, but instead a video camera [7]. Furthermore, Bosner et al [1] have not stated what pre-study information was available to the GPs involved as this could similarly influence GP behaviour. In addition, as the project was conducted in only 12 practices and associated with only one university (in Marburg, Germany) there must be a degree of caution with extrapolating the findings to teaching across all GP settings.
Whilst some of the improvements can be interpreted from our suggested limitations, such as evidence of appropriate training and mechanisms in place for quality assurance; we have made additional recommendations after reflecting on our own clinical experiences.
At several points the authors have touched on factors that could help form a vital role in helping understand the reasons behind GP’s verification and feedback, however these have not been developed. For example, Bosner et al [1] differentiates practices as “urban” or “rural,” but have not stated their findings for particular GPs. Walter et al [8] found that students in the rural setting performed better in their exams, and hence this distinction may have been informative. Table 2 lists patients’ reason for attending the clinic, ranging from “health education,” to “acute threatening.” This could similarly influence the time the GPs had for student interaction. It therefore may have been of use to stratify the points from Table 1 and 2 with findings of their respective observation sessions, to allow for any correlations to be drawn. Similar organisation of observation findings between field observed and video camera recording sessions may highlight any potential bias in the GPs behaviour as referred to above.
Finally a further subdivision of the feedback given should have been to categorise whether a constructive element was present. Joyner et al [9] noted constructive feedback as an important feature of medical student learning and development.
In conclusion, we were pleased to read this review and the recommendations for more specific feedback in general practice placements. We agree that such feedback will help undergraduate medical students progress as better clinical practitioners. However, some of the limitations discussed above do impact the use of this study in shaping medical education. Furthermore, identifying the barriers would assist medical educationalists in forming solutions to solve these issues.
References:
1. Bösner, S., Roth, L.M., Duncan, G.F. and Donner-Banzhoff, N., 2017. Verification and feedback for medical students: an observational study during general practice rotations. Postgraduate medical journal, 93(1095), pp.3-7.
2. Ende, J., 1983. Feedback in clinical medical education. Jama, 250(6), pp.777-781.
3. Poulos, A. and Mahony, M.J., 2008. Effectiveness of feedback: The students’ perspective. Assessment & Evaluation in Higher Education, 33(2), pp.143-154.
4. Lempp, H. and Seale, C., 2004. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. Bmj, 329(7469), pp.770-773.
5. Website Accessed on 2/2/2017: http://www.kingshealthpartners.org/about-us/our-partnership
6. Lievens, F., 2001. Assessor training strategies and their effects on accuracy, interrater reliability, and discriminant validity. Journal of Applied Psychology, 86(2), p.255.
7. Baker, P.G., Dalton, L. and Walker, J., 2003. Rural general practitioner preceptors–how can effective undergraduate teaching be supported or improved. Rural and Remote Health, 3, p.107.
8. Walters, L., Worley, P., Prideaux, D. and Lange, K., 2008. Do consultations in rural general practice take more time when practitioners are precepting medical students?. Medical education, 42(1), pp.69-73.
9. Joyner, B. and Young, L., 2006. Teaching medical students using role play: twelve tips for successful role plays. Medical teacher, 28(3), pp.225-229.
The correct statement is as follows:
The portion of the stomach within which H. pylori localises has profound
impact on its clinical sequelae. H. pylori colonization of the antrum
results in increased acid production which may lead to duodenal ulcer
formation. On the other hand, infection within the body of the stomach
predisposes individuals to atrophic gastritis, which, in turn, may
progress to precancerous lesions a...
The correct statement is as follows:
The portion of the stomach within which H. pylori localises has profound
impact on its clinical sequelae. H. pylori colonization of the antrum
results in increased acid production which may lead to duodenal ulcer
formation. On the other hand, infection within the body of the stomach
predisposes individuals to atrophic gastritis, which, in turn, may
progress to precancerous lesions and gastric cancer.
The article states:
=======================================================The portion of the
stomach within which H. pylori localises has profound impact on its
clinical sequelae.18 H. pylori infection within the body of the stomach
results in increased acid production and peptic ulcer disease. On the
other hand, infection of the antrum predisposes individuals to atrophic
gastritis, which, in turn, may progress to preca...
The article states:
=======================================================The portion of the
stomach within which H. pylori localises has profound impact on its
clinical sequelae.18 H. pylori infection within the body of the stomach
results in increased acid production and peptic ulcer disease. On the
other hand, infection of the antrum predisposes individuals to atrophic
gastritis, which, in turn, may progress to precancerous lesions and
gastric cancer. =======================================================
The gastric location of the above statements is incorrect and
reversed. Infection of the antrum, not body, results in increase acid
production leading to ulcer disease. Vice-versa, infection of the body,
not antrum, results in atrophic gastritis and may lead to malignancy.
I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.
I would like to share the experience in our country. Singapore is a country in Sout...
I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.
I would like to share the experience in our country. Singapore is a country in South-East Asia. All public hospital junior staff communicate via mobile technology. There are no bleeps. Mobile technology is an essential communication tool. A majority of junior doctors, housemen and medical officer grades are employed by a government-linked company, which gives out monthly mobile phone subscription fee subsidies. Mobile phone numbers of doctors are published on the hospital intranets. As the mobile phones are always with the doctors, each doctor is more easily accessible and can attend to patients in a swifter manner, potentially improving patient care. Consequently, many doctors carry two mobile phones around - a personal phone and a work phone. The same work mobile phone with an internet subscription allows the doctor to access journals, articles and databases literally at his finger tips.
There is potential in mobile technology and I urge interested parties to embrace it.
I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
Show MoreChoice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive...
Dear authors,
Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.
As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.
Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.
Earlier this year a cohort study at the University of Dundee showed t...
Show MoreSir,
Show MoreIn recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine be...
Dear Sir,
It was a pleasure reading Fitzgerald’s study on provision of research/audit opportunities and skills required to conduct such projects[1]. As medical-students, it was revealing to read statistics on how our contemporaries reported lack of formal research opportunities and training. As part of Europe’s largest medical school[2], one with a strong reputation that no doubt hinges on viable research output, we were not surprised by these results.
Though we agree with the article’s conclusions, we’d like to offer our thoughts on factors affecting student output and improvements that could be made.
From our experience, the main ways students are granted research opportunities are through Student Selected Components (SSCs) and intercalated BScs. Timescales for these are 5-6 months, with most having a shorter duration. Usually this is enough for a topic introduction, let alone information accumulation for an acceptable paper. Moreover, iBSc-derived research offers opportunities to access respected research teams and get better publications. We know students published in Nature due to their iBSc modules[3]. However, these modules are invariably oversubscribed, meaning students without sufficient marks are often excluded. Lastly, because of time and location demands on students during clinical years, it is likely most student publications come from research exposure during iBSc. The importance of this publication route needs further investigation....
Show MoreI was disappointed by this attempt to rebut my hypothesis.
My hypothesis was not inchoate (OED “confused or incoherent”) as they obviously understood exactly what I wished to suggest – the conventional wisdom might be wrong or at least need some modification and that Carbon dioxide excretion may play a part in weight regulation.1
We agree that the general public and health professionals are bewildered about weight regulation. That is not a reason to stop thinking and restate conventional wisdoms.
We agree that “the majority of people they surveyed believed that that ”fat shed during weight loss was converted to energy rather than excreted as carbon dioxide and water.” That is not a reason to stop thinking and rely upon conventional wisdoms. I recall a paper that made the point that exhaled Carbon Dioxide might be relevant to fat loss.2 Indeed most people seem to assume that weight can be lost purely by energy production “raised metabolic rates” without a net excretion of heavy atoms but this is a conventional wisdom that is only correct in nuclear reactors in which E=mc2.
Of course self –reporting of food intake is notoriously unreliable. But do we condemn as recidivists3 all those whose weigh loss plateaus on a diet? The same paper suggested a metabolic resistance to the maintenance of a reduced body weight. I merely provided a possible mechanism for this.
We agree that “diets only succeed when the age-old advice to eat less and mov...
Show MoreFake peer review: the many faces
Viroj Wiwanitkit1
1. Honorary Professor, Dr Dy Patil University, Pune Inida
Email: wviroj@yahoo.com
I read the recent publication by Cheung BMY with a great interest [1]. In fact, this problem is not uncommon and can be seen elsewhere.
Reviews that seem overtly positive can be a clue for suspicious fake reviewing. It is the role of the journal editor to select the reviewer and consider the quality of the review. The fake reviewing might be by a non-existent (totally fake) person or a disguised reviewer. Sometimes, it can be a totally biased reviewer who is recommended by the submitting author.
In addition, a similar problem can also be seen in academic presentations, proposal decisions, funding decisions, as well as academic position appointment decisions. In some underdeveloped countries, it is surprising that non-scientific reviewers can act as academic reviewers when academic work is under consideration. This reflects a poor standard and should be considered as an unacceptable misconduct.
conflict of interest
None
References
1. Cheung BMY. Fake peer review - too good to be true. Postgrad Med J. 2017 Jun 7. pii: postgradmedj-2016-134506.
Conflict of Interest
None declared
Dear Editor,
It was with great pleasure that we read the observational study by Bosner et al [1] which centres on an aspect salient to all medical students: clinical teacher feedback [2][3][4]. A factor highlighted by Lempp et al, found that students were most pleased with teachers who were approachable and provided them with constructive criticism [4].
As undergraduate medical students at the largest centre for healthcare education in Europe [5], we benefit from experiences in varied teaching settings; ranging from one-to-one sessions to class sizes of up to 450 students. Our clinical curriculum places strong emphasis in the primary health care setting - where we have accumulated nearly 300 hours between us in around 40 practices, both in and around London.
Whilst Bosner et al [1] have presented a well-organised and structured study; we challenge some of the intricacies affecting its overall validity and subsequent conclusions, and therefore propose suggestions for improvements. There is an absence of information pertaining to whether the observers (fifth year medical students) were appropriately trained to effectively judge the quality of feedback given by their seniors (clinical teachers). This is then coupled with no mention of any guidelines or reference used as a “benchmark” for this assessment. Both present issues regarding quality assurance - the necessity and impact of which has been highlighted by Lievens [6].
The presence of the ob...
Show MoreThe correct statement is as follows: The portion of the stomach within which H. pylori localises has profound impact on its clinical sequelae. H. pylori colonization of the antrum results in increased acid production which may lead to duodenal ulcer formation. On the other hand, infection within the body of the stomach predisposes individuals to atrophic gastritis, which, in turn, may progress to precancerous lesions a...
The article states: =======================================================The portion of the stomach within which H. pylori localises has profound impact on its clinical sequelae.18 H. pylori infection within the body of the stomach results in increased acid production and peptic ulcer disease. On the other hand, infection of the antrum predisposes individuals to atrophic gastritis, which, in turn, may progress to preca...
Dear Editor,
I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.
I would like to share the experience in our country. Singapore is a country in Sout...
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